External review: your rights after a final internal denial.
When you've exhausted a payer's internal appeals on a medical-necessity or coverage denial, an independent external review lets a reviewer with no stake in the outcome decide — and that decision is binding on the plan. It's one of the strongest levers left after a final internal denial, because the payer no longer controls the reviewer.
What actually matters
- External review applies mainly to denials based on medical necessity, experimental/investigational calls, and certain coverage decisions
- You generally must exhaust internal appeals first, then request external review within the stated window (often ~4 months)
- An Independent Review Organization (IRO) decides — and its decision binds the plan
- Fully-insured plans follow the state external-review process; self-funded plans follow the federal process
- Expedited external review exists for urgent situations where waiting would jeopardize care
Common questions
Is an external review decision binding on the insurer?
Yes. If the independent reviewer overturns the denial, the plan must cover the claim. That independence and finality is what makes external review powerful after internal appeals fail.
Who can request external review — the provider or the patient?
Typically the patient or their authorized representative; a provider can often pursue it as the patient's authorized representative. The right and the process depend on whether the plan is state-regulated or self-funded.
Where Volari fits: For medical-necessity denials that survive internal appeals, external review is the next lever — and it rewards the same substantiated, documentation-anchored case Volari builds from the start.
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